Revenge of the blue crab cake

The case A 26-year-old moderately obese woman presented to the emergency department (ED) with progressive abdominal pain and nausea. She was found to have tenderness over a preexisting 4-cm-diameter umbilical hernia and was posted to the operating room (OR) for an exploratory laparotomy and repair of likely incarcerated hernia. She denied any medical problems or allergies. Despite the curious aroma of Old Bay seasoning, the patient vehemently denied having had anything to eat or drink for 2 days! “Couldn't even get out of bed! I promise!” she said. Hmmm…Her sister and several friends who had accompanied her to the ED exchanged a few anxious glances before agreeing – nothing to eat or drink within the past 48 hours. In the OR, she underwent a standard intravenous induction, followed by easy mask ventilation. Then the inevitable occurred. Before the trachea was intubated, the patient vomited copious amounts of undigested food. What a mess! Trying hard not to swear under your breath, you manage to place an endotracheal tube after aggressively suctioning and manually clearing her oropharynx. Hoping that the worst of it is over, you patiently wait for the beep of the pulse oximeter to return to normal. Unfortunately, her SpO₂remains in the 85% to 90% range, despite now being on 100% oxygen and increased positive end-expiratory pressure (PEEP). You call for a bronchoscope and take a look; you see large amounts of particulate matter, clearly recognizable as…crab cake?.